1. Aloneness (ALO)
Keeps to the edges of a group or isolates himself/herself from it;
cuts off communication.
No spontaneous approaches; no offering of objects.
Does not use objects as a means of mediation.
Uses the adult as an object.
Behavioral Summarized Evaluation-Revised (BSE-R)
The BSE-R Scale is designed to provide a quantitative evaluation of autistic behavior in developmentally disordered children. Each item is scored from 0 to 4 according to the frequency of appearance.
0 = Never 1 = Sometimes 2 = Often 3 = Very often 4 = Always
A cross should be put against the estimated score for each symptom in the column opposite.
No Item 0 1 2 3 4
1 Aloneness (ALO) 2 Ignores people (IGN) 3 Poor social interaction (SOC) 4 Abnormal eye contact (GAZ)
5 Does not make an effort to communicate using voice and/or words (VOI) 6 Lack of appropriate facial expression and gestures (GES)
7 Stereotyped vocal or verbal utterances, echolalia (ECH) 8 Lack of initiative, poor activity (ACT)
9 Inappropriate relating to inanimate objects or to doll (OBJ) 10 Irresistible and/or ritual use of objects (RIT)
11 Intolerance of change and to frustration (SAM) 12 Stereotyped sensorimotor activity (STE) 13 Agitation, restlessness ( AGI)
14 Bizarre posture and gait (POS) 15 Auto-aggressiveness (AGR) 16 Hetero-aggressiveness (HGR) 17 Mild anxiety signs (ANX) 18 Mood difficulties (MOO)
19 Disturbance of feeding behaviour (EAT)
20 Does not try to be clean (stools or urine), plays with stools (CLE) 21 Individual bodily activities (BOD)
22 Sleep problems (SLEP)
23 Unstable attention, easily distracted (ATT) 24 Bizarre responses to auditory stimuli (AUD) 25 Variability (VAR)
26 Does not imitate the gestures and voices of others (IMI) 27 Child too floppy, lifeless (TON)
28 Does not share emotion (EMO)
29 Paradoxical sensitivity to touching and contact (TOU)
5. Does not make an effort to communicate using voice and/or words (VOI)
Here assessment should be based on the effort towards communication and not on verbal level. A child with speech can make no effort to communicate and score a high mark (noncommunicative echolalic language). A child without speech can try to make himself/herself understood in his/her own way (burbling, prattling) and score a low mark.
6. Lack of appropriate facial expression and gestures (GES) Amimia. Facial immobility.
Shows no anticipatory postural reaction when about to be picked up.
Cannot direct the examiner’s hand to obtain a desired object:
does not wave hands in its direction: cannot indicate precisely what s/he wants by gesture, attitude, or look.
If s/he can speak, does not use facial, vocal, or gestural expression with normal frequency and liveliness.
7. Stereotyped vocal or verbal utterances, echolalia (ECH) Immediate or delayed echolalia; repeats randomly or selectively.
Inversion of the personal pronoun.
Repeats words or phrases whether or not they have communicative value.
Links together words and phrases based on certain key words or consonances irrespective of any logical connection between them. Example: lemon, Monday, daylight, etc.
Utters stereotyped sounds (‘ah,’ ‘oh’) in an abrupt, jerky way at moments of disappointment or delight: at other times for no particular reason.
8. Lack of initiative, poor activity (ACT)
Does not invent any games without prompting (though possibly quite capable of doing so).
Passivity; lack of interest.
Slowness.
9. Inappropriate relating to inanimate objects or to doll (OBJ)
Ignores objects or shows only fleeting interest in them (the object is held in a haphazard way without visual fixation on it).
Sucks or puts objects into mouth.
Pats, taps or strikes them repeatedly.
Unusual behavior towards objects; lets them drop from hands passively: strokes them.
Pulls hand away from a building block as if it were red-hot:
minute tactile examination of things; tends to become absorbed by meaningless marks: stains, holes, dots.
Bizarre and very personal utilization of objects and/or strange, eccentric behavior; will place an object on its side, or turn it round and round. Always carries a piece of string. Picks up anything lying around.
10. Irresistible and/or ritual use of objects (RIT)
Irresistible, uncontrollable need for an object, always keeps it with him/her, whether or not s/he uses it.
Always uses objects in the same way and for the same purpose.
11. Intolerance of change and frustration (SAM) Insistent demand that everything remains unchanged.
Has great difficulty in accepting anything unusual: changes of place, time, people, clothes, food. Such changes provoke disproportionate reactions.
Frustrated, reacts angrily when forbidden something or when activities are interrupted: discontented when desires or expectations remain unsatisfied. Becomes fixated on the frustrating element.
12. Stereotyped sensorimotor activity (STE) Stereotyped activities can also be noticed in the gait:
Rocks to and fro on the bed, on the ground or from one foot to the other.
Drums feet.
Plays ‘eye-games’ in sunlight or electric light.
13. Agitation, restlessness (AGI)
Such symptoms occur in periods of rest or directed activity.
Restlessness: disordered, uncontrolled, aimless excitation.
Seems unable to find any peace, is constantly on the move.
Boisterousness: seems compelled to make a noise and be generally troublesome. Boisterousness can be considered normal, but pathological when exaggerated. It is therefore taken into account in the assessment.
Example: climbs everywhere, jumps from chair to chair, touches everything, is constantly changing activities, spreads out objects or toys. Can also be very noisy and deliberately seek out noise
‘like a tornado’.
14. Bizarre posture and gait (POS)
Strangeness is often evident in posture and gait but it can also extend to general behavior and activities.
Facial expression: grimaces, bizarre facial movements
Posture: feet crossed in the air, head underneath; twisted body;
unbalanced posture; legs folded, head against the feet: hunched up in the corner of a room; neck bent backwards; violent extensions of the body; absence of postural anticipation; poor postural adaptation (the ‘soft’ or ‘slippery’ child).
Gait: hops, walks on tiptoe or on the heels; turns round and round or runs round in little circles; walks dragging one foot;
walks sideways with strange sudden forward movements.
15. Auto-aggressiveness (AGR)
Aggression directed against or mutilation of own body (hits head with hand or some object, lets himself/herself fall heavily to the ground, bites, pinces himself/herself, scratches face, etc.).
16. Heteroaggressiveness (HGR) Bites, scratches, hits out at other people.
17. Mild anxiety signs (ANX)
Examples of manifestations of anguish and anxiety:
Sudden fits or crying, whimpering (often without tears) Little nervous laughs
Seems fearful, fretful, uneasy Aimless walking up and down Trembling
Somatization: vomiting, hyperventilation or retention of breath, intestinal problems (constipation, diarrhea), sweating, nail-biting.
18. Mood difficulties (MOO) Difficulty in registering emotion
Alternation of opposite emotions (anger, laughter, pleasure, sadness)
Unprovoked fits of temper and laughter.
19. Disturbance of feeding behavior (EAT) Qualitative and/or quantitative difficulties
Passive indifference: allows himself/herself to be fed without affective participation.
Active refusal: cries or screams at the sight of food, refuses to be fed, gesticulating and turning the head away.
Exclusive choice of certain tastes: sweet or salty.
Eats other things (stones, paper).
Coprophagy.
Meryscism: ‘ruminates’.
Vomiting.
Eats dirtily, smears the food or throws it away.
Rituals.
Absence of the sense of taste.
Bulimia, anorexia.
20. Does not try to be clean (stools or urine), plays with stools (CLE)
It is necessary to appreciate the efforts to be clean and not
21. Individual bodily activities (BOD) Including:
Solitory stimulation of sensitive areas of body, particularly sexual areas (masturbation).
Seeks or avoids ‘skin’ contact with others: sexual games, problems with bodily contact.
Disinterested in body, no handling of parts of the body (mouth, anus, sexual organs, skin).
The child avoids bodily contact during washing, dressing, etc.
Avoids being touched.
22. Sleep problems (SLEP)
Hypersomnia (sleepy, difficult to waken).
Hyposomnia (too awake, active, excitable). The child can remain awake and calm.
Disturbed sleep (screams, cries, complains, nightmares, nightfears).
Sleep rituals (needs a presence, certain positions).
23. Unstable attention, easily distracted (ATT)
The child is incapable of fixing his attention on any suggested activity.
Takes no notice of what is said to him/her on any suggested activity.
Slowness of integration: does not take in instructions or does so only after a delay.
Delayed responses.
Unstable attention: modifications of attention are triggered by minute changes in the environment.
Abnormal attention: pays attention to own nonvocal sound productions (scratching, tapping), which s/he listens to very attentively.
24. Bizarre responses to auditory stimuli (AUD)
Heightened importance of the auditory function in a certain kind of relation with the outside world.
Excessive, insufficient, or selective sensitivity to noises, sounds, calls.
Paradoxical responses. Example: the child does not turn head when a door slams or when his/her name is called and interests himself/herself instead in the sound of rustling paper.
25. Variability (VAR)
Considerable, even extreme, variations in capacities or problems from one minute to another.
These variations may also involve behaviour with others in the form of aggressive rejection or possessive attachment.
26. Does not imitate the gestures or voices of others (IMI) Incapable of copying movements of hands, head, mouth or of copying postures and does not imitate sounds (not to be confused with echopraxia or echolalia).
27. Child too floppy, lifeless (TON) Hypotonic child, limp.
28. Does not share emotion (EMO)
Does not seem sensitive to emotion expressed by others. The expression of his/her emotion does not fit with that of others.
29. Paradoxical sensitivity to touching and contact (TOU) Physical contact with objects or people are sometimes avoided and sometimes accepted, even sought.
Remarks
Certain considerations that could suddenly modify the scores should be clearly indicated: e.g., child changes group or treatment, the nurse or teacher changes etc.
© Catherine Barthélémy. Reproduced by permission.
Time 15 minutes Ages 18 months
Time Frame Not specified
Purpose Assessment of autistic behavior.
Commentary
The CHAT was designed for the early identification of autism in children aged 18 months. Key items of the CHAT focus on two behaviors: 1. joint attention, e.g.
looking to where a parent is pointing; 2. pretend play, e.g.
pretending to pour tea from a toy teapot. If children are lacking these behaviors at age 18 months, they are at risk for a social-communication disorder.
Versions
The Checklist for Autism in Toddlers (CHAT) is only available as one form that includes questions for both parents and primary health care workers.
Properties
Items The CHAT comprises 14 items. The first 9 items are asked to the parents, and the last 5 items are made by the primary health care worker. All items are rated on a 2-point scale with responses: yes, and no.
Scales The items of the CHAT are not scored on subscales. Instead, the CHAT has 5 key items and if children fail on these items they have a high risk of developing autism. Children who fail on 2 specific key items have a medium risk of developing autism.
Reliability No information available.
Validity In a population-screening study of 16 000 18-months-old children the CHAT was able to detect children with a diagnosis of autism with a sensitivity of 18% and a specificity of 100%, and to detect children with all pervasive developmental disorders with a sensitivity of 21% and a specificity of 100%.
Norms No information available.
Use The CHAT and further information can be downloaded from the website of the Autism Research Centre.
Key references
Baron-Cohen S, Allen J, Gillberg C. Can autism be detected at 18 months? The needle, the haystack, and the CHAT. Br J Psychiatry 1992; 161: 839–43.
Baron-Cohen S, Wheelwright S, Cox A, et al.
Psychological markers in the detection of autism in infancy in a large population. Br J Psychiatry 2000; 168:
158–63.
Baron-Cohen S, Cox A, Baird G, et al. Early
identification of autism by the Checklist for Autism in Toddlers (CHAT). J R Soc Med 2000; 93: 521–5.
Address
Simon Baron-Cohen
Autism Research Centre (ARC) Cambridge University
Douglas House 18b Trumpington Road Cambridge CB2 2AH UK
www.autismresearchcentre.com